02/1976
February 1976
The Giant Killers
Tom D. Throckmorton
Dr. Tom D. Throckmorton, M.D., has received degrees from Drake University, Northwestern University Medical School, and the University of Minnesota. He has served as a Fellow in Surgery at the Mayo Clinic, and as a member of surgical, teaching and consulting staffs in a number of hospitals. He presently practices general surgery in Des Moines, Iowa.
This presentation was given in the Center for Constructive Alternatives seminar on nationalized health care titled, "The Sound Body: An Apple-a-Day Dilemma."
When memory keeps me company, I sometimes see, through childhood's eyes, Old Beecher's iron-shod hooves striking sparks from the cold, hard paving bricks of Main Street. Henry Ward Beecher was grandfather's faithful carriage horse. As the short winter day deepened into night, grandfather locked his roll-top desk, banked the fire in the reception room stove and shrugged himself into a voluminous horsehide overcoat. He then topped himself off with a sealskin cap and turned the big key in the front door of the office. The sign said "Dr. Tom Morford Throckmorton." Scooping me up under one arm, he mounted into the lurching buggy and tucked me close beside him under a large buffalo robe. This robe smelled not only of its original occupant, but also of horse and dust, and that marvelously complex smell of medicine. Old Beecher knew the way home and took the last corner at a brisk trot. His hoof beat rang out into the frosty air, and the sight of those rhythmically swaying haunches together with the scattering showers of sparks held me spellbound.
Grandfather was a regulation, iron-clad, copper-riveted, old-fashioned country doctor. He practiced in a county seat town and knew every soul and most of the animals within a radius of fifteen miles. And that radius just about encompassed his lifetime. His lifetime spanned the expansion of surgery from amputations to the invasion of the abdominal cavity and the skull. He saw the germ-theory developed and proved. He owned one of the first microscopes in the state: a wonderously glittering brass-barrelled instrument prominently displayed beneath a glass bell-jar—and seldom moved for actual use.
He compounded his own medicines, and proved both the safety and palatability of each bottle by shaking it briskly and then licking the cork He was stern but beloved by the community. I have watched him hitch up a rig by lantern light and drive from the shelter and wavering shadows of the barn into the face of a dark, cold March rain—without a grumble. He brought an almost palpable sense of equanimity with him into an anxious household, but little else. His tools were pitifully inadequate to the task. I have the old gentleman's saddle bags, for he rode horseback when the bottomless gumbo clay would not tolerate a buggy during the spring thaw. They contain a variety of powders, pills and potions, but only three curative drugs: quinine, digitalis and mercury. Nonetheless, he brought almost a thousand babies into the world; he cut and sutured when needed; he allayed symptoms and fears alike. He treated patients, and God healed them. Grandfather was a towering giant in his community. At least half-a-hundred little boys wanted to grow up and be like "old Doc"—a term of love and respect, never used to his face.
In 1875 grandfather swung off the Rock Island and onto the station platform. Just graduated from medical school in Philadelphia, he came equipped with a sheepskin diploma, a set of amputating knives in a teakwood case, and a full, deep chestnut beard which he hoped would disguise his youth and testify to his wisdom. When he died in 1941, the Methodist church was filled and his pallbearers were all old patients. Later, when his will was probated and apportioned by law, my share came to less than twenty dollars.
His accounts, kept in a flowing Spencerian hand, reflected thousands of dollars in unpaid receivables; yet, mankind was his business and his charities were numerous. Grandfather must have valued his charities, because he always kept them well hidden.
I come from a family that has always believed in giants. Many is the time I have heard father and grandfather discussing their old professors: the elder Gross and the younger Gross, W. W. Keen and DeCosta. Their admiration for their own giants was obvious. But I had my giants to think about, for there were giants in those days—men like grandfather and father. Father was a towering figure. He used words like honor, fortitude, charity, integrity, responsibility, dedication and love: these and many other such terms, now rusty with disuse, seemed to carry very specific meanings for him.
Father was a tremendously capable physician: general practitioner, scientist, neurologist, professor, and finally one of the original diplomates of the American Board of Neurology and Psychiatry.
Father didn't have the horse and buggy problem, but on many a fine brisk sub-zero morning I have watched him pour a tea kettle of hot water over the manifold and carburetor of his Model T Ford car before old Tin Lizzie would shake herself into life. And father had some real tools with which to work: clinical laboratory tests were burgeoning, electrocardiography was a new fad, x-rays were increasingly reliable, and truly potent drugs such as arsphenamine and salvarsan became available. He was chief-of-staff at his hospital, was the secretary of the Iowa State Medical Society for many years, and declined an opportunity to be vice-president of the A.M.A. He was an establishment man—and he was his own man. I worked in the same office with him for eighteen years. We never had a harsh word; we truly admired each other. When father died, his funeral cortege was enormous. The newspaper ran a lengthy editorial captioned "The Beloved Physician." His passing was swift. He had been a frugal man, had educated four sons, and his top income for any year had been less than $20,000.
Giants like those two great men, father and grandfather, are now seldom seen. Somehow when the old giants left the stage and disappeared into the wings of obscurity, their places were taken by men of lesser caliber: men frustrated by their roles, men so enmeshed in details that the thread of the plot seemed lost, and men who seemed to take a lesser pleasure in their work. Here and there a delightful anachronism does still exist, but by and large the old medical giants have vanished from the scene. Let us see if the causes of their disappearance can be found.
Specialization
As a beautiful woman is all things to all men, so the old doctor represented all of medicine to the patient. Then, the surgeon came along. His mechanical wizardry made him an adept in one area. The medical doctor and the surgeon tended toward a high regard for each other, and cooperation was the rule between them. They needed each other.
Then came the pediatrician who suffered the little children to come unto him, up to and including age sixteen. When mother had taken Junior to a "baby specialist" she could not very well go back to the old family doctor for the delivery of her next child, so the obstetrician was created. From the obstetrician came the gynecologist, who had especial knowledge of female problems. And then the office gynecologist and the gynecological surgeon. And finally the gynecologic oncologist, who deals only with the treatment of certain tumors occurring in women.
These are obvious examples of the splintering of medical practice into bits and pieces. Obviously, the old giant who treated people has been replaced by a horde of well-trained experts who treat certain sexes, or ages, or organs, or regions of the body, or diseases, or whose treatment is limited to a single modality. The fragmentation of the patient into piecemeal components made most of the great old medical giants superfluous. They were accustomed to treating whole patients, who were sick.
New techniques, new modalities of treatment, and new knowledge were expensive. Elegant medical measures required the exotic setting of a hospital. Medical costs increased. More and more patients got well in shorter and shorter periods of time, but at greater expense. To be sure, the patient was returned to his job or his family in fewer days than before, but at greater initial cost. The principles of insurance offered a welcome solution to the problem. It is possible to calculate the risk of recurrent but unforeseen events and spread the cost over a wide base. Medical and hospital insurance were born. These were indemnity plans; they paid scheduled amounts for certain things, and the patient so protected did not usually expect the payments to cover the entire cost of his illness. Some of these policies paid only if struck by lightning on a clear day; others paid fairly satisfactory amounts, depending upon what the patient bought.
"Full Medical Coverage"
The hospitals, whose accounts receivable were sometimes staggering, fashioned Blue Cross. Hospital Service, Inc. told patients that they deserved to have their hospital bills paid in full at the time of discharge. To do so merely required a larger premium and a little actuarial legerdemain. Blue Cross soon found a short cut in adding up and paying citizen John Doe's bill. The hospital costs per bed per day were easily calculated. Instead of paying Mr. Doe's actual costs, Blue Cross found it simpler to reimburse the hospital on a cost per bed per day formula—with an added 5 percent for good behavior. Thus, America's hospitals were soon operating as cost-plus corporations. This is the least efficient method of administration with which I am familiar. It pays a premium for inefficiency and makes for the willy-nilly expansion of facilities and services beyond need or demand. Everyone went to the hospital—first class.
The doctors did not lag far behind. We invented Blue Shield. This concept was quite different. It guaranteed the full payment of those medical services, rendered in an accredited hospital, according to a fee schedule if the patient's income was below a certain level. If the income was above this amount, the payments served as an indemnity toward the physician's customary fees. This scheme guaranteed the physician's charity to the shorn lamb, but otherwise paid but a portion of his usual charges. The kindly old medical giant, still reeling from the inroads of the specialists, found himself enmeshed in fee schedules and knee deep in paper work.
Big Business and Big Labor
About this time society developed a new, excruciating pain in the pocket nerve—it was being repeatedly stimulated by something called "income tax." The laboring man resented leaving a portion of his pay check with his employer each week to apply on his federal income tax. Both labor and management began a keen search for "fringe benefits"; i.e., a payment to the employee in tax exempt goods or services. It didn't take long to zero in on health care as such a foolproof "tax deduct." And so, physicians quickly found themselves the object of barter between labor and management. Health care, through insurance, became a fringe benefit. The bartering was brisk over the services of physicians, who seemingly could do little about it. And if the insurance provisions were not adequate, the onus somehow or other always fell upon the doctor—never upon the provision of inadequate coverage. The poor old giant, wading in a deepening morass of paper, found himself venial and avaricious if he did not respond to union demands or corporate fee schedules.
The Progressive Education of Medicine
During these times a thing called "progressive education" happened. This was the system in which no one failed. It was wrong to confront a student with his inadequacies (although none knew them better than he); and it was a definite "no no" to imply that all of God's children might not be of equal potential. Therefore, the application of a "means test" to medical insurance suddenly became a degrading criterion. No one should be forced to regard himself as a recipient of charity—not even a little bit of charity. Everyone should be allowed to stand straight and tall in his own eyes, and have his medical bills paid in full by some sort of socio-economic magic. The old doctor was told his charities were neither desirable nor needed; a strict adherence to a multitude of fee schedules and the employment of another person to expedite his office paper work would assure the old giant of a proper star in his crown.
The Middlemen
Haven't you noticed the burgeoning of a horde of people who feel their lot in life is to package, wrap and sell? "They toil not; neither do they spin." This I call the Saran Wrap and Scotch Tape crowd. They are utterly unproductive. They never produce a marketable service or make a real thing. Yet, somehow or other, they feel a divine right to help you package and distribute your services or the product of your labor. Their pitch goes something like this: "Doctor, the techniques you have mastered and the invaluable services you perform are the products of an intensive scientific education and experience. Such an education, though to be admired, is a narrow thing at best and really does not fit you to distribute its benefits to a suffering and imploring humanity. Please continue your work and your self-discipline and turn the drudgery of your work and the problems of its distribution over to us. We understand those other laws of supply and demand. Let us light the darkest corner of the deepest ghetto with the hope—nay the realization—of proper medical care."
The government is literally teeming with these little people who are utterly unproductive, but who feel compelled to process, wrap and distribute your thing—in this case medical care. For thirty years these little people have been swarming annually, like termites; since all lesser measures have failed, they say, the provision and distribution of medical care by the government is the only remaining answer.
These little people change their cutting edge from time to time: from Murray-Wagner and Dingwell to Edward Kennedy and Rogers. But the thrust always remains the same. They claim that private enterprise has failed miserably to answer the health needs of our country; big government must step in and order our lives—healthy, happy lives—from womb to tomb.
These "wrappers and distributors" have been at it for a long, long time. Let's look at their record. The United States mail! Need I say more? Years ago a penny postcard written and posted by 9 a.m. in Des Moines was delivered across town by 1 p.m. Now, a ten cent first-class letter may take three days—or it may not arrive at all. [Ed. note: Since this presentation was given, the rate has risen to thirteen cents.] How would you like to turn your health needs over to Amtrak—or to the National Park Reservation Service? Ask yourself if you are ready to apply the know-how of Social Security to your health care. A bankrupt Social Security! A Social Security dependent upon tomorrow's taxes for yesterday's promises. Perhaps we should have the Pentagon conducting the bidding and purchasing of medical supplies and facilities.
It must be clear by now that a consortium of little faceless people is determined to help you run your business more effectively, with you as the fall guy when your own house tumbles about your ears—tumbling after they have shifted its foundations and removed the rafters as unnecessary and expensive items.
The old medical giant today would be as helpless as a beached whale. The faceless Saran Wrap and Scotch Tape crowd has belittled and degraded his chief stock in grade—a magnificient individuality.
Alas, the Virtuoso
In the scheme of fee schedules, somehow or other the virtuoso has been ignored. There are obviously virtuosi of the theater and stage and gallery; and there are virtuoso performances given daily in operating theaters, sick rooms and laboratories. You and I would never confuse the exploding colors of a Van Gogh or the delicate brush strokes of a Monet with one of those rectilinear daubs sometimes labeled "modern art." A cadenza ripped from the piano by a Horowitz cannot be equated with "Peter, Peter, Pumpkin-eater"—even though they both use the black and white keys. The same differentiation is true in medicine. A tremendous, lifesaving improvisation by a master surgeon must somehow be reduced to a code number which fits into a fee schedule so that the computer will not be confused. A masterpiece of surgery or diagnosis must necessarily be equated with the tentative, hopeful efforts of the youngest tyro. I believe this impersonal measure of ability has been the spade which has beaten down the last clods on the graves of the old medical giants. True, they were all human; but some of their efforts were truly superhuman.
Let us review the obituary of the old medical giants:
- New tools and new knowledge diluted their aura; and new advances were even more rapidly exceeded by the expectations of the public.
- Specialization in medical practice divided the human body into zones and diseases for the more efficient application of a new knowledge and therapy. But too often super-specialization has made the patient an "interesting case," not an anxious, suffering human. Specialization fragmented the old doctor; and the busily evolving body of medicine could find little use for the splinters and shards.
- Insurance and fee schedules came between the old physician and his patient. A third party wrote the check and a third party complained about the fee. There is no record of a third party ever saying "Thank you, well done!"
- The "cost-plus" operation of hospitals soon made the patient, the physician and all medical care the victim of an inefficient, upward spiraling economy.
- Business and labor made medical care a tax exempt fringe benefit. Willy-nilly the physician found himself in no man's land without a spade.
- Charity was erased; charity became a bad word. Charity vanished because society would rather care for its unfortunates by check than become personally involved. The physician had been personally involved because of empathy, discipline and because it was expected of him. These expectations have been replaced by rigid fee schedules and the machinations of a social worker.
- The middlemen, the Saran Wrap and Scotch Tape crowd, sought to reduce the physician to a role of technician and chancre mechanic. They also have helped most other forms of private enterprise toward the embrace of socialism.
- The virtuoso was replaced by the mediocre. A sort of waist-high medicine was born, and sold as the answer to all health problems.
Thus, the great old medical giants are gone—gradually killed by forgetfulness and by all those things that have made today what it is: new science, new social pressures, the mixing and friction of social strata, the cry of the middleman that "I am my brother's keeper" (and I know what he needs, even if he doesn't), and finally, a submission to mediocrity because it colors all of us gray.
The story of American medicine is the story of America. We are allowing our socialistic elements, who have repeatedly failed to cope, to blame us for their failures! To be sure, medical care in the ghetto is unsatisfactory. The answer is not to prostitute medicine into a cheap, over-the-counter remedy. The answer is to do away with the ghetto. This is not a medical problem; this is a social problem. Medicine cannot solve the predicament of the small town, the agricultural community, the growing difficulties of transportation, the agonies of racial strife, unemployment waste or war. You need but right the social and economic wrongs and you will find American medicine able to cope with the problems of American health. America's health problems are not going to be remedied by a grandiose plan which sprinkles physicians, like indentured servants, about the country. Nor will these problems be solved by creating a medical juggernaut into which the sick are funneled for a computerized evaluation and treatment by the numbers.
The real problems of American medicine are a sickening government, an ailing economy, a satisfaction with mediocrity and a frightened group of little people who have gotten all of us into these difficulties, and are nervously waiting for a hand on their lapels to lead them back to stability and to sanity.
My greatest fear is that the people of our country will not recognize this situation for what it is. The times are out of joint—the cart is truly before the horse. Our medical care system is distorted and torn by the very economic system which malfunctions when confronted by social injustice and excesses, from whatever source. I fear the next step may be fatal to American medicine: a well-meaning but inept attempt to correct social ills by a re-ordering of the structure of medical care into a national health care plan. Such a distortion is unthinkable and yet it is proposed. An attempt, utterly mad, is being made to place American medicine as the entering wedge of a new socialism. The currently proposed national health schemes are like grandfather's saddle bags: there is scarcely a thing in them to influence the grave, underlying maladies which disrupt America.
Despite grandfather's attributes, no one wants to return to bedside medicine. No one with lobar pneumonia would trade a massive dose of penicillin for grandfather's calm, bearded face leaning over the bed. And yet, realizing the course that American medicine has been forced to take, I think few of us would want to turn it over to the Postal Service or Amtrak for re-evaluation and distribution. Our government for many years has spent well beyond its means. It has maintained a standard of living that has been the envy of all nations, until they discovered our inability to cope with our own debt. And now, universal health care is proposed, a medical care that "costs us practically nothing," since it is to be paid for by the government. In closing, let me recall an oft-repeated adage of my father: "There is no such thing as a free lunch."
Copyright © 2011 Hillsdale College. The opinions expressed in Imprimis are not necessarily the views of Hillsdale College. Permission to reprint in whole or in part is hereby granted, provided the following credit line is used: “Reprinted by permission from Imprimis, a publication of Hillsdale College.” SUBSCRIPTION FREE UPON REQUEST. ISSN 0277-8432. Imprimis trademark registered in U.S. Patent and Trade Office #1563325.
© 2007-09 Hillsdale College. All rights reserved.